What does it mean to be ‘in recovery’? We need a better federal definition

“When I use a word,” one of 19th century British author and mathematician Lewis Carroll’s characters once said, “it means just what I choose it to mean — neither more nor less.”

Though he was a formidable philosopher and logician, Carroll likely would be stymied by the circular logic that justifies the definition of “recovery” currently used to support critical federal substance use disorder programs and activities. For more than a decade, the federal government has been using an imprecise, nebulous, and informally developed “working definition” of “recovery” to support critical federal substance use disorder programs. Ultimately, that imprecise definition may undermine rather than advance important national substance use disorder treatment and policy goals.

The  2022 National Drug Control Strategy of the Office of National Drug Control Policy (ONDCP), for example, uses the word “recovery” 314 times as it explains seven “specific strategic goals and objectives for the Nation to reduce the demand for and availability of illicit drugs and their consequences.” Under the goal “Recovery efforts are increased in the United States,” ONDCP calls for “recovery-ready workplaces,” “recovery support services,” “recovery coaching, “recovery housing,” and support for “recovery community organizations,” all essential components of “building a recovery-ready Nation.”

But what does it really mean to be in “recovery” from a substance use disorder? Rather than developing or promoting its own definition, the 150-page National Drug Control Strategy instead relies on and cites a 2010 working definition from the Substance Abuse and Mental Health Services Administration (SAMHSA), an operating division within the Department of Health & Human Services.

SAMHSA’s 2010 working definition says recovery means: “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

It came up with this definition after assembling unidentified “leaders in the behavioral health field, consisting of people in recovery from mental health and substance use problems” and engaging in further “consultation with many stakeholders,” who were also unnamed. The 2010 SAMHSA document identifies 10 “Guiding Principles” of recovery including “hope,” “person-driven,” “holistic,” “peer support,” and “relational.”

While there was opportunity for public input in 2011, the working definition does not appear either at the time or since to have been subject to any external, formal peer review or public comment period. The brief document cites in support of its guiding principles no papers or scientific studies. This document seems, in short, a shaky foundation on which to build programs or support a key part of a national strategy intended to reflect coordination across 19 federal departments and agencies as part of a $41 billion national drug control budget.

SAMHSA itself now has created an entire Office of Recovery that will “evaluate and initiate policy, programs and services with a recovery focus and ensure the voices of individuals in recovery are represented.” That new Office of Recovery’s website in turn also cites in its resources the SAMHSA 2010 working definition for recovery.

This imprecise language that pervades the nation’s most important and well-publicized behavioral health strategies is anathema to another of the Drug Strategy’s important goals — that of supporting “evidence-based” policies, approaches and solutions (variations of which are used 86 times in the Strategy).

“‘You are in recovery if you say you are’ and you are welcome,” according to one author quoted in the National Drug Control Strategy’s discussion of this goal, which further references the “23 million Americans in recovery,” or about 7 percent of the current U.S. population.

That perhaps is the central failure of recovery under the working definition. It is so open-ended and informal that it seemingly can mean anything to anyone and is open to everyone — and this, in the end, dilutes its meaningfulness and utility.  This also makes it more likely that grants and other programs will suffer from this same lack of precision with respect to outcomes and outcome measures.

A recent executive summary from a 2022 SAMHSA meeting on recovery indicates no plans to develop a new, more precise definition. Put simply, the 2010 Working Definition relied on by federal policymakers more than a decade later would benefit from an update — this time as part of a more formal process that reflects and is fully supported and informed by established peer-reviewed science, ethical and policy considerations.

We need a transparent and public process to develop an improved federal definition of recovery. Because the federal definition of recovery can impact funding, program outcomes and policies, such as ONDCP’s strategy, it’s important for that definition to be up-to-date and evidence-based. We should know who is involved in formulating this strategy and how any draft definition is revised to reflect their input.

In developing an updated recovery definition, the federal government would ideally consider current scientific literature on recovery and the recovery process. The updated definition would cite and reference peer-reviewed and other reports. It would reflect international norms.

An updated definition also would reflect public input and participation from SAMHSA’s peer agencies such as the National Institutes of Health (including the National Institutes on Alcohol Abuse and Alcoholism, Mental Health, and Drug Abuse), Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services as well as ONDCP, the Department of Justice and others with interest and programs in this area. The process of developing a revised definition would be led and driven by federal staff in collaboration with the public, not outsourced to contractors or consultants. Public input into the definition both from individuals and organizations representing older adults, youth, racial and ethnic minorities, law enforcement, tribal populations, health care providers, veterans and others would be specifically solicited.

An updated recovery definition would not only allow for comment through listening sessions or meetings but also be published in the Federal Register with a public docket on Regulations.gov so we would know who commented and what they said. (Anonymous comments still may be made when submitting comments to a public docket for those who do not want to share their personal information). The updated definition or an explanation of the definition would be published in a peer-reviewed journal, where it would ideally be subject to the journal’s standard process of independent peer review.

Lack of precision with the term “recovery” in the substance use world in some ways mirrors similar methodological problems with the term “serious mental illness,” which also is subject to variation that impacts federal programs. Developing a revised and more precise and scientific definition or recovery in a transparent manner would improve the nation’s substance use disorder programs. It also would ultimately help those with substance use disorders and their friends, family, and health providers.

There is every reason to support those recovering from current and past substance use disorders. But we need a more precise, scientific, and shared understanding of just what recovery really means.

Mitchell Berger has worked in public and behavioral health at the federal and local levels. The opinions expressed are solely his and should not be imputed to any other individual nor to any public or private entities.